Developmental Reserch

In order to provide the best service to people who join the support group, all we ask is a few details. By maintaining a record of where people live, we may even know somebody in your area with a CS person in their family. Our records are Strictly Confidential, and the information will never be passed on to a 3rd party. With your help we can get a better understanding of Costello Syndrome. Thank you

* = Required

Mothers First Name	*	Required
Mothers Last Name	*	Required
Mothers age when child with CS was born	*	Required
Fathers First Name	*	Required
Fathers Last Name	*	Required
Fathers age when child with CS was born	*	Required
Name of the person with Costello Syndrome	*	Required
Date of birth (day/month/year)	*	Required
House Number	*	Required
Address Line 1	*	Required
Address Line 2
City	*	Required
Zip / Post code	*
State/Province (US/Canada only)		Required
Country	*	Required
Phone number	*	Required
Email Address	*	Required

Please help us to understand Costello Syndrome better, by answering the following Questions:-

Person w/Costello's head circumference, at birth.		Use the closest Measurement.
Person w/Costello's head circumference, at each birthday. Please enter all that apply in the form of birthday /size - for instance, 1st/46 cm, 2nd/48cm, 3rd/50cm, etc		Use Inches or CM
Person w/Costello's weight at birth
Person w/Costello's weight at each birthday. Please enter all that apply in the form of birthday/weight for instance, 1st/6 kg, 2nd/12 kgs, 3rd/17kg, etc."		Use Pounds and Ounces or KG
Person w/Costello's length at birth
Person w/Costello's length , at each birhday, please enter all that apply in the form of - 1st /50 cmlength 2nd / 80 cm length etc		Use Inches if that is your unit of Measurement.
Tested positive for HRAS mutation		Yes No Not Tested

The age (in months) / years when the following happened

First smile
Sat alone
Crawled
Walked - with support
Walked --alone
When first teeth came through:-
Toilet trained --day YES/NO		Yes No
If yes, at what age was daytime toilet training successful
Toilet trained --night: YES/NO		yes no
If yes, at what age was nighttime toilet training successful
Has your child tube fed? YES/NO		Yes No
If YES what was the age when tube feeding stopped
Age when eating stopped being a problem
Age at independent eating:
Sexual maturity --age it happened:
Has growth hormone been used		YES NO
If yes at what age did you start using growth hormone
If yes at what age did you stop using growth hormone

Please Note: Only press the Submit button once, as the server can take up to 60 seconds to upload your form. Many thanks.

Web site and all contents © Copyright ICSSG, 2008 All rights reserved.
This website or any portion of this website may not be reproduced, duplicated, copied, sold, resold, visited, or otherwise exploited for any commercial purpose without our express written consent.
The contents of this website may be freely used for the purpose of education, and training, or any not for profit use which is of benefit to the costello community